Question 1

The nurse has just completed an assessment on a patient with a fractured right femur.Which data will the nurse categorize as objective?

Accepted Answer

A)  The patient's toes of right foot are warm and pink. 
B)  The patient reports a dull ache in the right hip. 
C)  The patient says feels tired all the time. 
D)  The patient is concerned about insurance coverage. 
A)  The patient's toes of right foot are warm and pink. 
B)  The patient reports a dull ache in the right hip. 
C)  The patient says feels tired all the time. 
D)  The patient is concerned about insurance coverage.

Question 2

A home health nurse is providing care to a patient.Which action by the nurse is a physical care technique?

Accepted Answer

A)  Dressing a patient 
B)  Assisting a patient to learn how to shop 
C)  Performing range-of-motion exercises 
D)  Administering cardiopulmonary resuscitation 
A)  Dressing a patient 
B)  Assisting a patient to learn how to shop 
C)  Performing range-of-motion exercises 
D)  Administering cardiopulmonary resuscitation

Question 3

A nurse develops a nursing diagnosis for a patient.What is the rationale for the nurse's actions?

Accepted Answer

A)  It allows a nurse to compete with physicians or health care providers. 
B)  It allows a nurse to develop an individualized plan of care. 
C)  It allows a nurse to treat nursing problems and medical problems. 
D)  It allows a nurse to manage patient care for the entire health team. 
A)  It allows a nurse to compete with physicians or health care providers. 
B)  It allows a nurse to develop an individualized plan of care. 
C)  It allows a nurse to treat nursing problems and medical problems. 
D)  It allows a nurse to manage patient care for the entire health team.

Question 4

A nurse wants to provide patient-centered care to a patient of another culture.Which question is the most culturally sensitive when talking about a patient's illness?

Accepted Answer

A)  "What do you call your problem?" 
B)  "How long has your child had the runs?" 
C)  "When did you last void today?" 
D)  "Has anyone else in your family had diarrhea?" 
A)  "What do you call your problem?" 
B)  "How long has your child had the runs?" 
C)  "When did you last void today?" 
D)  "Has anyone else in your family had diarrhea?"

Question 5

A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy.Which will provide the best primary source of information for what comforts the patient when stressed?

Accepted Answer

A)  Patient chart 
B)  Patient 
C)  Parents 
D)  Surgeon 
A)  Patient chart 
B)  Patient 
C)  Parents 
D)  Surgeon

Question 6

A patient with bilateral pneumonia is admitted to the intensive care unit.The nurse who initially prepared the plan of care identified that the patient had the collaborative problem of Potential complications: hypoxemia.What made the nurse classify this as a collaborative problem?

Accepted Answer

A)  It requires ensuring adequate hydration. 
B)  It requires monitoring for signs of acid-base imbalance. 
C)  It requires evaluating the effects of positioning on oxygenation. 
D)  It requires both nursing and physician-prescribed interventions. 
A)  It requires ensuring adequate hydration. 
B)  It requires monitoring for signs of acid-base imbalance. 
C)  It requires evaluating the effects of positioning on oxygenation. 
D)  It requires both nursing and physician-prescribed interventions.

Question 7

Which question or comment should the nurse initially use that would best gather the most information during a health history assessment?

Accepted Answer

A)  "Let us help you." 
B)  "Did you seek help when it first started?" 
C)  "Tell me about the problems you are having." 
D)  "Do you have a family history of this problem?" 
A)  "Let us help you." 
B)  "Did you seek help when it first started?" 
C)  "Tell me about the problems you are having." 
D)  "Do you have a family history of this problem?"

Question 8

A patient has an outcome of ambulating three times a day.The patient does not ambulate the entire day.What should the nurse do next?

Accepted Answer

A)  Walk the patient. 
B)  Reassess the patient. 
C)  Change the goal for the patient. 
D)  Continue with the plan for the patient. 
A)  Walk the patient. 
B)  Reassess the patient. 
C)  Change the goal for the patient. 
D)  Continue with the plan for the patient.

Question 9

A nurse is delegating care of patients to the nursing assistant personnel (NAP)and a licensed practical nurse (LPN).Which situation indicates the nurse needs more instruction on delegation?

Accepted Answer

A)  LPN to change a sterile dressing 
B)  NAP to provide skin care 
C)  NAP to insert an indwelling catheter 
D)  LPN to administer an enema 
A)  LPN to change a sterile dressing 
B)  NAP to provide skin care 
C)  NAP to insert an indwelling catheter 
D)  LPN to administer an enema

Question 10

A patient has lost 10 pounds in the last 2 months from breast cancer and chemotherapy.The chemotherapy has caused the patient to not eat.Which nursing diagnosis should the nurse use to develop the plan of care?

Accepted Answer

A)  Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Food Intake 
B)  Imbalanced Nutrition: Less Than Body Requirements Related to Cancer 
C)  Imbalanced Nutrition: Less Than Body Requirements Related to Loss of Weight 
D)  Imbalanced Nutrition: Less Than Body Requirement Related to Insufficient Prescription of Chemotherapy 
A)  Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Food Intake 
B)  Imbalanced Nutrition: Less Than Body Requirements Related to Cancer 
C)  Imbalanced Nutrition: Less Than Body Requirements Related to Loss of Weight 
D)  Imbalanced Nutrition: Less Than Body Requirement Related to Insufficient Prescription of Chemotherapy

Question 11

A postoperative patient is continuing to have incisional pain.As part of the nurse's assessment,the nurse notes that the patient is grimacing when he or she changes position.The patient's grimace can be useful in the assessment and can be described as which of the following?

Accepted Answer

A)  Cue 
B)  Inference 
C)  Diagnosis 
D)  Health pattern 
A)  Cue 
B)  Inference 
C)  Diagnosis 
D)  Health pattern

Question 12

A nurse is caring for a patient and performs several interventions.Which action by the nurse is an independent nursing intervention?

Accepted Answer

A)  Turning every 2 hours 
B)  Administering a medication 
C)  Inserting an indwelling catheter 
D)  Starting an intravenous (IV) for intravenous fluids 
A)  Turning every 2 hours 
B)  Administering a medication 
C)  Inserting an indwelling catheter 
D)  Starting an intravenous (IV) for intravenous fluids

Question 13

A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status.What should the nurse do next?

Accepted Answer

A)  Modify the care plan. 
B)  Discontinue the care plan. 
C)  Create a nursing diagnosis that states goals have been met. 
D)  Reassess the patient's response to care and evaluate interventions. 
A)  Modify the care plan. 
B)  Discontinue the care plan. 
C)  Create a nursing diagnosis that states goals have been met. 
D)  Reassess the patient's response to care and evaluate interventions.

Exam 9: Nursing Process

The nurse has just completed an assessment on a patient with a fractured right femur.Which data will the nurse categorize as objective?

A home health nurse is providing care to a patient.Which action by the nurse is a physical care technique?

A nurse develops a nursing diagnosis for a patient.What is the rationale for the nurse's actions?

A nurse wants to provide patient-centered care to a patient of another culture.Which question is the most culturally sensitive when talking about a patient's illness?

A 2-year-old patient is being admitted to the outpatient surgery for a tonsillectomy.Which will provide the best primary source of information for what comforts the patient when stressed?

A patient with bilateral pneumonia is admitted to the intensive care unit.The nurse who initially prepared the plan of care identified that the patient had the collaborative problem of Potential complications: hypoxemia.What made the nurse classify this as a collaborative problem?

Which question or comment should the nurse initially use that would best gather the most information during a health history assessment?

A patient has an outcome of ambulating three times a day.The patient does not ambulate the entire day.What should the nurse do next?

A nurse is delegating care of patients to the nursing assistant personnel (NAP)and a licensed practical nurse (LPN).Which situation indicates the nurse needs more instruction on delegation?

A patient has lost 10 pounds in the last 2 months from breast cancer and chemotherapy.The chemotherapy has caused the patient to not eat.Which nursing diagnosis should the nurse use to develop the plan of care?

A postoperative patient is continuing to have incisional pain.As part of the nurse's assessment,the nurse notes that the patient is grimacing when he or she changes position.The patient's grimace can be useful in the assessment and can be described as which of the following?

A nurse is caring for a patient and performs several interventions.Which action by the nurse is an independent nursing intervention?

A patient has met the goals and outcomes mutually agreed upon for improvement of ventilatory status.What should the nurse do next?

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